Microvascular Flap Reconstruction Research Articles

Evaluating Pedicled Pectoralis Major Myocutaneous Flap Reconstructions for Oral Malignancy and the Influence of Laterally Based Rotational Advancement Flap on Donor Site Integrity and Nipple Position in Male Patients.

Oral cancer poses a significant health burden, particularly in the male population of India. This study focuses on evaluating the outcomes of 48 pedicled Pectoralis major myocutaneous (PMMC) flap reconstructions in male patients with oral malignancy. Given the challenges associated with microvascular flap reconstructions, especially in advanced cancer cases, older patients, and resource-constrained settings, the PMMC flap still serves as a valuable alternative. The study introduces a novel approach by incorporating a laterally based rotational advancement flap (LBRA) to address donor site integrity and decrease the nipple-areolar complex (NAC) displacement. Traditionally, PMMC flap designs tend to cause inward shifting of the NAC during chest donor site closure, impacting the aesthetic outcome. Surgical techniques involved wide local resection, neck dissection, and PMMC flap reconstruction. The Flap design included a horizontal orientation with adjustments based on defect location. Additionally, a laterally based rotational flap from the chest aided in donor site closure. Results demonstrate the versatility and reliability of PMMC flap reconstructions, with no total flap necrosis or major complications observed in the 48 cases. The LBRA technique effectively mitigated NAC displacement. The study contributes to the existing literature by providing insights into the advantages of PMMC flap reconstructions and introducing a technique to optimize donor site closure and decrease the medial shifting of the nipple. The adaptability, reliable vascular supply, and simplified learning curve make the PMMC flap a preferred choice in resource-constrained settings with high patient demand. In conclusion, this research underscores the continued relevance and effectiveness of the PMMC flap in head and neck reconstruction, offering satisfactory cosmetic and functional results. The introduction of the LBRA technique adds a nuanced dimension to improve outcomes, particularly in male patients with oral malignancy.

Premastectomy Radiotherapy and Immediate Breast Reconstruction

Premastectomy radiotherapy (PreMRT) is a new treatment sequence to avoid the adverse effects of radiotherapy on the final breast reconstruction while achieving the benefits of immediate breast reconstruction (IMBR). To evaluate outcomes among patients who received PreMRT and regional nodal irradiation (RNI) followed by mastectomy and IMBR. This was a phase 2 single-center randomized clinical trial conducted between August 3, 2018, and August 2, 2022, evaluating the feasibility and safety of PreMRT and RNI (including internal mammary lymph nodes). Patients with cT0-T3, N0-N3b breast cancer and a recommendation for radiotherapy were eligible. This trial evaluated outcomes after PreMRT followed by mastectomy and IMBR. Patients were randomized to receive either hypofractionated (40.05 Gy/15 fractions) or conventionally fractionated (50 Gy/25 fractions) RNI. The primary outcome was reconstructive failure, defined as complete autologous flap loss. Demographic, treatment, and outcomes data were collected, and associations between multiple variables and outcomes were evaluated. Analysis was performed on an intent-to-treat basis. Fifty patients were enrolled. Among 49 evaluable patients, the median age was 48 years (range, 31-72 years), and 46 patients (94%) received neoadjuvant systemic therapy. Twenty-five patients received 50 Gy in 25 fractions to the breast and 45 Gy in 25 fractions to regional nodes, and 24 patients received 40.05 Gy in 15 fractions to the breast and 37.5 Gy in 15 fractions to regional nodes, including internal mammary lymph nodes. Forty-eight patients underwent mastectomy with IMBR, at a median of 23 days (IQR, 20-28.5 days) after radiotherapy. Forty-one patients had microvascular autologous flap reconstruction, 5 underwent latissimus dorsi pedicled flap reconstruction, and 2 had tissue expander placement. There were no complete autologous flap losses, and 1 patient underwent tissue expander explantation. Eight of 48 patients (17%) had mastectomy skin flap necrosis of the treated breast, of whom 1 underwent reoperation. During follow-up (median, 29.7 months [range, 10.1-65.2 months]), there were no locoregional recurrences or distant metastasis. This randomized clinical trial found PreMRT and RNI followed by mastectomy and microvascular autologous flap IMBR to be feasible and safe. Based on these results, a larger randomized clinical trial of hypofractionated vs conventionally fractionated PreMRT has been started (NCT05774678). ClinicalTrials.gov Identifier: NCT02912312.

WITHDRAWN: Outcomes and influential factors in functional and dental rehabilitation following microvascular fibula flap reconstruction in the maxillomandibular region: A systematic review and meta-analysis

WITHDRAWN: Outcomes and influential factors in functional and dental rehabilitation following microvascular fibula flap reconstruction in the maxillomandibular region: A systematic review and meta-analysis

Role of Infrared Thermography in Planning and Monitoring of Head and Neck Microvascular Flap Reconstruction.

Reconstruction using microvascular free flaps has become the standard of care in head and neck cancer surgery, and their success lies in appropriate planning, adequate revascularization, and early detection of flap compromise so that prompt salvage is possible. This study evaluates the role of infrared thermography in the planning, execution, and postoperative monitoring of microvascular flaps in head and neck reconstructions. This is a single institutional, prospective observational study conducted at a tertiary care hospital in South India for 13 months. Twenty patients were included, and their thermographic images were captured in the preoperative, intraoperative, and postoperative settings using the infrared camera FLIR T400. These images were analyzed along with the Doppler, and clinical monitoring findings in all the settings and the temperature difference were calculated postoperatively. Hotspot perforator marking was made using infrared camera, and perforator marking was made using hand-held Doppler preoperatively, which correlated in 93% of cases. Intraoperatively, flap rewarming was successfully demonstrated in 19 of 20 cases. Postoperatively, flap compromise was observed on infrared thermography during the first 24 hours but not on clinical monitoring in three cases. The temperature difference values recorded were 5.4°C, 2.4°C, and 4.9°C. The mean of temperature difference of the healthy flaps was 1.0°C (range 0.1°C-1.8°C). Infrared thermography provides simple and reliable imaging, which can be used in perforator marking and flap designing preoperatively and checking the flap perfusion and vascular anastomosis patency intra- and postoperatively.

Postoperative Changes in Systemic Immune Tolerance Following Major Oncologic versus Minor Maxillofacial Surgery.

There is increasing evidence of the benefits of adjuvant and neoadjuvant immunotherapy in the treatment of solid malignancies like oral squamous cell carcinoma (OSCC). To optimize (neo-)adjuvant treatment, the systemic immunomodulatory effects of tumor surgery itself need to be considered. Currently, there is little evidence on the immunological effects of major surgery, such as free microvascular flap reconstruction. The current study aims to analyze how and to what extent maxillofacial surgery affects systemic parameters of immune tolerance. A total of 50 peripheral whole blood samples from patients (Group 1 (G1) = extensive OSCC surgery; Group 2 (G2) = free flap reconstruction without persistent malignant disease; Group 3 (G3) = minor maxillofacial surgery) undergoing surgery were included for real-time quantitative polymerase chain reaction (RT-qPCR) to examine changes in mRNA expression of the biomarkers IL-6, IL-10, FOXP3, and PD-L1. Blood samples were taken immediately before and after surgery as well as on the second, fourth, and tenth postoperative days. Differences in mRNA expression between groups and time points were calculated using statistical tests, including Mann-Whitney U-test and Pearson correlation analysis. Comparing postoperative expression of G1 and G3, there was a significantly higher PD-L1 expression (p = 0.015) in G1 compared to G3 and a significantly lower IL-6 (p = 0.001) and FOXP3 (p = 0.016) expression. Interestingly, IL-10 expression was higher pre- (0.05) and postoperative (p < 0.001) in G1 compared to G3. Additionally, in G1, there was a significant overexpression of IL-10 post-surgery compared to the preoperative value (p = 0.03) and a downregulated expression of FOXP3 between pre- and 2 d post-surgery (p = 0.04). Furthermore, there was a significant correlation between the duration of surgery and the perioperative expression changes of the analyzed biomarkers. As the duration of surgery increased, the expression of IL-10 and PD-L1 increased, and the expression of IL-6 and FOXP3 decreased. Extensive surgery in OSCC patients is associated with a transient shift toward postoperative systemic immune tolerance compared with patients undergoing minor surgery. However, even extensive surgery causes no signs of long-lasting systemic immunosuppression. The degree of immune tolerance that occurred was associated with the duration of surgery. This supports efforts to minimize the duration of surgery.

Detailed Analysis of Three Major Breast Reconstructions Using BREAST-Q Responses From 1001 Patients.

Patient-reported outcomes have become as important as mortality and morbidity in the postoperative evaluation of breast reconstruction surgery. The BREAST-Q is one of the most widely used patient-reported outcomes for breast reconstruction. A comparative analysis of the scores on each of the BREAST-Q modules could help analyze different reconstruction methods. However, few studies have utilized BREAST-Q for this purpose. The aim of this study was therefore to compare breast reconstruction methods in terms of BREAST-Q module ratings. The authors retrospectively reviewed the data of 1001 patients who had been followed for more than 1 year after breast reconstruction. The 6 BREAST-Q modules were rated on a scale of 0 to 100 and statistically analyzed by multiple regression. In addition, Fisher's exact test was performed after dividing the responses to each question into high- and low-rating groups. Microvascular abdominal flap reconstruction scored significantly better than implant-based reconstruction on all modules, except psychosocial and sexual well-being. In terms of satisfaction with the breast, latissimus dorsi flap reconstruction was superior to implant-based reconstruction. However, in terms of the reconstruction method, there were no differences in patients' willingness to make the same choice again or whether they regretted having surgery. The results highlight the superiority of autologous breast reconstruction. Reconstruction methods should only be performed after a thorough explanation of their characteristics to achieve results that meet patient expectations. The findings are useful for facilitating patient decision-making in breast reconstruction.

Recipient vessels for free flaps in advanced facial oncologic defects

ObjectivesTo prospectively compare the results of microvascular flap reconstruction of midface and scalp advanced oncologic defects using superficial temporal versus cervical as recipient vessels. MethodsThis is a parallel group clinical trial with 1:1 allocation ratio of patients who underwent midface and scalp oncologic reconstruction with free tissue flap from April 2018 to April 2022 in a tertiary oncologic center. Two groups were analyzed: those in whom superficial temporal vessels were used as the recipient vessels (Group A) and those in whom cervical vessels were used as the recipient vessels (Group B). Patient gender and age, cause and localization of the defect, flap choice for reconstruction, recipient vessels, intraoperative outcome, postoperative course, and complications were recorded and analyzed. A Fisher’s exact test was used to compare outcomes between the 2 groups. ResultsOn the basis of the different recipient vessels, 32 patients were randomized into 2 groups, and of these 27 patients completed the study: Group A with superficial temporal recipient vessels (n = 12) and Group B with cervical recipient vessels (n = 15). There were 18 male and 09 female patients with an average age of 53.92 ± 17.49 years. The overall flap survival rate was 88.89%. The overall complication rate for vascular anastomosis was 14.81%. The total flap loss rate in patients with superficial temporal recipient vessels was higher than the complication rate in those with cervical recipient vessels but with no statistical significance (16.67% vs. 6.66%, p = 0.569). Minor complications occurred in 05 patients without statistical significance between the groups (p = 0.342). ConclusionIn the group with superficial temporal recipient vessels, the postoperative rate of free flap complications was similar than the cervical recipient vessel group. Therefore the use of superficial temporal recipient vessels for midface and scalp oncologic reconstruction could be a reliable option.

Patient Specific Alloplastic Implant Reconstruction of Mandibular Defects-Safe Practice Recommendations and Guidelines.

Mandibular continuity defects are commonly seen after tumor resection, osteomyelitis or maxillofacial trauma. Three-dimensional reconstruction of these mandibular segmental defects is critical for proper mandibular functioning and esthetics. Various methods used to reconstruct such defects include bridging reconstruction plates, modular endoprosthesis, non-vascularized and vascularized bone grafting with stock reconstruction plate or patient specific implants (PSI) and tissue engineering bone transfer. But in the recent years, literature documents use of PSI only alloplastic reconstruction as an alternate to microvascular bone flap reconstruction. Representative cases enumerate current practice of 'patient specific implant only' mandibular reconstruction and its pitfalls. This article discusses current status of literature on PSI's, choice of indications for 'PSI only' mandibular reconstruction and also proposes guidelines for safe practice of patient specific implant reconstruction of mandible.

Comparison of Lymphatic Drainage of the Lower Limbs After Soft Tissue Reconstruction by Microvascular Muscle Flap Versus Fasciocutaneous Flaps.

Complex traumatic injuries of the lower limb are increasingly being salvaged. The common long-term morbidity includes secondary lymphedema. The role of microvascular flaps is often discussed for lymph flow restoration. However, the differential effect of using muscle flap versus fasciocutaneous flap in the lower-limb trauma to avoid secondary lymphedema is not studied. Forty patients who underwent microvascular flap reconstruction were reviewed retrospectively to obtain data regarding clinical demographics and surgical procedure. Assessment for presence of clinical lymphedema was done. The lymphatic drainage in all these patients was assessed by 99mTc lymphoscintigraphy. Of the 40 patients included in the study, group A (n = 23) underwent muscle-based free flap reconstruction, and group B (n = 17) had fasciocutaneous flaps. Clinical lymphedema was present in 21 patients, of which 18 were of group A and 3 of group B. On lymphoscintigraphy, 14 patients had either partial or complete obstruction in the reconstructed lower limb, 11 in group A and 3 in group B. All of them (n = 14) were found to have associated clinical lymphedema. The association of clinical lymphedema (P < 0.001) and obstructive pattern on lymphoscintigraphy (P < 0.05) with muscle flaps was found to be statistically significant. With the advancement in surgery and techniques, not only salvageability but also stable and morbidity free outcomes are the goals. Fasciocutaneous flaps may have better lymphatic outcomes than the muscle-based flaps, and the criteria for lower-limb reconstruction can be reformed to include simultaneous soft tissue and lymphatic reconstruction.

Occipital Artery-Based Fascio-Cutaneous Pedicle Flap in Reconstruction of Head and Neck Defects: A Saviour Under Challenging Times.

Head and Neck cancer management has undergone many changes in the past few decades. Primarily advancements in reconstructive surgery for complex head and neck defects after extensive ablative surgeries. Many factors need to be considered in deciding the type of reconstruction. Any reconstruction is not without complications. We wish to present the reconstructive challenges we faced in recent times to reconstruct composite head and neck defects, situation where a salvage flap has to be chosen in a failed regional flap. An occipital artery-based pedicled fascio cutaneous flap is one such rescuer flap. It is a retrospective study of case records from January 2018 to January 2021 at our institute. Reviewed the clinical data of Cases in which occipital artery-based flap was used to reconstruct the composite head and neck defects. In the era of microvascular flap reconstruction, utilization of regional flaps is still a choice of reconstruction in the resource constraint setting. A less explored occipital artery-based flap is a reliable regional flap can be used in select cases with a good success.

Association of low skeletal muscle mass and systemic inflammation with surgical complications and survival after microvascular flap reconstruction in patients with head and neck cancer.

BackgroundSkeletal muscle mass (SMM) and chronic inflammation are associated with postoperative complications and survival.MethodsPatients with head and neck cancer (HNC) undergoing microvascular free flap reconstruction were included. SMM and neutrophil‐to‐lymphocyte ratio (NLR) were measured and their association with treatment outcomes analyzed.ResultsFive hundred and fifty‐four patients were included. Predictors for complications were elevated NLR in all flaps (OR 1.5), low SMM in radial forearm flap (OR 2.0), and elevated NLR combined with low SMM in fibula flap surgery (OR 4.3). Patients with solely elevated NLR were at risk for flap‐related complications (OR 3.0), severe complications (OR 2.2), and when combined with low SMM for increased length of hospital stays (LOS) (+3.9 days). In early‐stage HNC, low SMM (HR 2.3), and combined elevated NLR with low SMM (HR 2.6) were prognostics for decreased overall survival.ConclusionsSMM and NLR are predictive for poor outcomes in patients with HNC undergoing microvascular reconstruction.

Superficial Circumflex Iliac Artery Perforator Flap in Advanced Head and Neck Reconstruction: From Simple to Its Chimeric Patterns and Clinical Experience with 22 Cases.

Head and neck tissue defects after ablative head and neck surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor-site morbidity. The authors present their experience with both simple and chimeric SCIP flap reconstructions for complex defects in various head and neck regions. Twenty-two patients undergoing ablative head and neck surgery for oncologic abnormalities were treated by means of a SCIP flap reconstruction. Patients' mean age was 62 years; 21 were men and one was a woman. Seventeen flaps were simple and five were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases. Twenty-one of 22 patients (95.5 percent) were successfully treated with good aesthetic and functional results. Two patients (9 percent) showed minor donor-site complications that were managed conservatively. The mean follow-up period was 5.3 months (range, 2 to 8 months). This case series demonstrates the reliability and versatility of the SCIP flap for head and neck reconstruction. The chimeric options combined with bone, double-skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgery. Intraoperative indocyanine green perfusion examinations are a valuable tool to assess and ascertain proper inset, vitality, and postanastomosis vessel patency in these complex microvascular flap reconstructions. . Therapeutic, IV.

The Impact of Metabolic Syndrome on Microvascular Head and Neck Reconstruction: An ACS-NSQIP data analysis

BackgroundMetabolic syndrome (MetS) can predispose patients to poorer surgical outcomes. In this study, we sought to evaluate the impact of MetS on the postoperative outcomes of head and neck microvascular reconstruction. MethodsReview of the 2015–2019 NSQIP database identified 5,323 cases of microvascular reconstruction, of which 3,809 were head and neck cases. Of the included patients, 184 had MetS and 3625 did not. The groups were compared in terms of demographics and comorbidities. Postoperative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and nonhome discharge. ResultsThe MetS group had higher rates of medical complications (p<0.0001), sepsis (p=0.02), septic shock (p=0.01), and skilled care-discharge (p=0.0004). Analysis by flap type revealed that MetS patients receiving free skin flaps experienced higher rates of organ space infection (p=0.02), sepsis (p<0.0001), and lower home-discharge (p=0.01). In the free muscle group, superficial incisional infection (p=0.04), UTI (p=0.02), and septic shock (p=0.01) were higher in MetS patients. Stratification by surgical site showed that the occurrence of sepsis was significantly higher in the patients receiving microvascular flap reconstruction of the larynx (p=0.04) or tongue(p=0.03). Stratification of the MetS patients according to treatment for diabetes showed that patients receiving insulin experienced a higher rate of superficial incisional infection (p=0.04). A multivariate analysis verified significantly higher rates of medical complications (p<0.0001), sepsis (p=0.03) and septic shock (p=0.01) in the MetS group. ConclusionPatients with MetS undergoing head and neck microvascular reconstruction are at increased risk of postoperative medical complications, including sepsis and septic shock, and are more likely to be discharged to a skilled care facility. Surgical outcomes were found to depend on the type of flap and site of surgery.

National Disparities in Autologous Breast Reconstruction

PURPOSE: Autologous breast reconstruction has evolved from more morbid procedures that sacrificed the patient’s abdominal muscle (the TRAM or transverse rectus abdominus muscle flap) to more elegant autologous reconstructions termed “perforator” flaps that spare fascia and muscle to harvest only the adipose tissue. Commercial insurers have recognized the higher technical demand for perforator flaps relative to other autologous reconstructions by creating separate procedural codes with significantly higher professional fees. This study examined whether a perforator flap procedure code unavailable with Federally issued Medicare or Medicaid disproportionally incentivizes perforator flaps among the commercially insured and, subsequently, patients from a higher socioeconomic status. METHODS: Autologous reconstructions performed between 2008 and 2014 were reviewed from the National Inpatient Sample using the ICD-9-CM procedure codes 85.72, 85.73, 85.74, 85.75, and 85.76. Extracted variables included age, race, comorbidities, hospital type, hospital region, insurance payer type, and median household income quartile. Autologous breast reconstruction was subdivided into microvascular perforator flaps (85.74, 85.75, 85.76), microvascular TRAM flaps (85.73), and pedicled TRAM flaps (85.72). Demographics, comorbidities, and access to care were compared between cohorts by chi-squared and ANOVA tests. A logistic regression comparing microvascular reconstructions only was created to predict the effects of insurance, geography, income quartile, and race on the likelihood of perforator flap reconstruction while controlling for age and comorbidities. RESULTS: After querying and weighting National Inpatient Sample data, 33,246 microvascular perforator flap breast reconstructions, 16,804 microvascular TRAM flap reconstructions, and 16,918 pedicled TRAM flap reconstructions were compared. The majority of patients undergoing autologous reconstruction were Whites (64.1%), with a mean age of 51.1 years. Patients receiving microvascular perforator flaps had fewer total comorbidities than patients receiving microvascular TRAM (P < 0.001) or pedicled TRAM (P = 0.003) flaps. Perforator flaps were significantly more likely among the commercially insured (perforator flap: 85.8% versus microvascular TRAM: 75.9% versus pedicled TRAM: 75.0%, P < 0.001), while TRAM flaps were more likely among patients with Medicare or Medicaid (perforator flap: 14.2% versus microvascular TRAM: 24.1% versus pedicled TRAM: 25.0%, P < 0.001). Patients of higher income quartiles were significantly more likely to receive perforator flap autologous reconstruction (P < 0.001). When comparing microvascular reconstruction, logistic regression revealed an odds ratio of 1.72 (P < 0.001) for perforator flaps among the commercially insured when compared with patients with Medicare or Medicaid. Income trends paralleled insurance status. When compared with the lowest income quartile, the second quartile had an odds ratio of 1.11 (P = 0.003) for perforator flap reconstruction, the third 1.07 (P = 0.029), and the fourth 1.36 (P < 0.001). Compared with rural locations, urban nonteaching hospitals had an odds ratio of 2.42 (P < 0.001) for perforator flap reconstruction and urban teaching hospitals had an odds ratio of 4.08 (P < 0.001). Asian patients had a higher odds ratio of receiving perforator flaps than White patients, with an odds ratio of 1.16 (P = 0.010). Black and Hispanic patients had comparable rates as White patients, with odds ratios of 0.97 and 0.95, respectively (P = 0.342, P = 0.192). CONCLUSIONS: Reimbursement incentives disproportionally favor perforator flap autologous reconstruction among the commercially insured. Differences across insurance status exaggerate already existing disparities in breast reconstruction across socioeconomic status.

Microvascular Flap Reconstruction for Head and Neck Cancers in Previously Operated and/or Radiated Neck: Is It Safe?

Microvascular reconstruction after oncologic resection with curative intent in recurrent or second primary cancer cases is challenging not only because of the complexity of the defect but also due to difficulty in finding suitable donor vessels in the neck that has already been subjected to surgery and subsequent adjuvant treatment. In our present study, we evaluated the success of free flaps, reexplorations, and factors associated with reexploration and with flap failures in previously operated and/or radiated neck. In this retrospective study, we analyzed patients who underwent microvascular reconstruction from January 2016 to December 2018 in patients with previous surgery and/or radiation, considered as "already treated neck" (ATN). These cases were reviewed to analyze variables that included age, sex, indication for surgery (recurrence, second primary, osteoradionecrosis, and secondary reconstruction), duration since previous surgery or radiation, free flap done, donor vessels used, the need to go to the contralateral neck or outside the neck, need for vein grafts, flap reexploration rate, flap survival rate, and hospital stay of the patients. We also tried to identify factors that predisposed for a reexploration after performing reconstruction with a free flap in ATN. Of 1522 free flaps done, 371 patients were included in the study. Flap success rate was 90.8% in ATN, which was comparable to naive neck (94%; P = 0.108). The reexploration rate in ATN (16.2%) was significantly higher (P = 0.0003) than in naive neck (9.8%). The previous treatment (neck dissection) received [P = 0.001; odds ratio, 13.7 (1.87-101.6)] was the most significant predisposing factor, and patients undergoing osteocutaneous flaps were more prone to undergo reexplorations (P = 0.05). Side of anastomosis, vessel used for anastomosis, comorbidities, and time since previous treatment did not affect the reexploration rate significantly. Microvascular reconstruction can be safely performed in ATN with good success rates, and it should not be a deterrent in whom free flap is required to achieve best functional outcome. However, it may be associated with increase in reexploration rates in the postoperative period. Patients having undergone a previous neck dissection are at more risk of undergoing this reexploration in comparison with radiotherapy (RT)/chemotherapy and radiotherapy (CTRT) alone.

Outcomes of Re-exploration Procedures After Head and Neck Free Flap Reconstruction.

This study was conducted to evaluate the outcomes of re-exploration procedures done after head and neck microvascular flap reconstructions. This is a retrospective review of 109 flaps in 106 patients (three patients had two flaps each) that underwent re-exploration procedures in 1001 consecutive free flap surgeries. The outcome was analysed in terms of the type of the flaps, re-exploration rate, flap salvage rate and overall flap success rate. Free radial forearm (RFF) was the commonest flap done (354, 35.3%). One hundred nine flaps underwent re-exploration procedures in 106 patients. Out of this, 79 flaps could be salvaged, and 30 flaps failed. There were also another ten flaps, which failed without any re-exploration. The overall re-exploration rate was 10.8%. The flap salvage rate was 72.4%. The overall flap success rate was 96.1%. Nearly three-fourths of the flaps with vascular compromise can be successfully salvaged with appropriate and timely intervention.

THREE DIMENSIONAL VIRTUAL PLANNING, MODELLING AND PRINTING IN FIBULA FREE FLAP MANDIBULAR RECONSTRUCTIONS – INITIAL CASE SERIES IN A LIMITED RESOURCE ENVIRONMENT

The most contemporary approach when dealing with extensive head and neck defects post oncological resections is based on virtual computer planning, surgical resection/reconstruction simulation and three dimensional modeling and printing. It is of great benefit, particularly when the maxillo-mandibular area is involved, because of its complex three dimensional form and active functional load, both these features presenting a long-standing reconstructive challenge to the head and neck surgeons. Developing such complex surgical techniques is a very resource dependent undertaking and relies substantially on a strategic support from the given National Health Service system. An overview of the first 3 consecutive cases of entirely digitally planned and lab-to-theatre transferred mandibular resections and simultaneous microvascular fibula flap reconstructions performed in Sofia between August – October 2017 is presented.

A Protocol for the Use of a Combined Microvascular Free Flap with Custom-Made 3D-Printed Total Temporomandibular Joint (TMJ) Prosthesis for Mandible Reconstruction in Children

Extended postoperative mandibular reconstructions due to orofacial disease involving the temporomandibular joint (TMJ) in immature patients remain a challenge as a result of ongoing growth, which is usually affected by the disease and treatment. Current reconstructive techniques based fully on alloplastic total joint replacement fail to meet fully the anatomical and functional requirements for the masticatory system and speech development. Fourteen children aged 12.6 ± 2.6 with tumors or congenital deformities affecting the mandible and TMJ were included in the study. Radical surgical treatment according to our own protocol was performed through microvascular anastomotic flap reconstruction of the soft tissues and bones, together with total TMJ custom replacements. Follow-up lasted 2–6 years. During the follow-up, increases in the mandible body (13% growth) and ramus (12% growth) were observed, both of which were related (p &lt; 0.001). This is the first report concerning the immediate reconstruction of the mandible with ramus and total TMJ in children and adolescents that combines a free vascularized graft and total individual prosthesis of the TMJ. The presented technique enabled optimal function of the TMJ, growth of the mandible, and further rehabilitation of the patients. The technique was demonstrated to be safe, reliable, and provide good functional and cosmetic outcomes.

Risk-Grade Classification of Progress of Disease in Patients Undergoing Multimodality Treatments for Recurrent or Metastatic HNSCC

Objective: Neither the factors that affect prognosis for recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) is not well investigated, nor are comparative efficacy of salvage treatments well assessed. To determine factors predicting the outcome after multimodality of treatments for R/M HNSCC, we classified the R/M HNSCC into three risk-grades based on progress-free survival time and investigated the tumor factors and treatments. Methods: A retrospective analysis was conducted at head and neck center of Sir Run Run Shaw hospital of clinical and follow-up data for 152 R/M HNSCC patients who underwent salvage surgery with or without microvascular flap reconstruction, salvage radiation, systemic treatments after prior unsuccessful cancer treatment using surgery, radiation, or chemotherapy. Results: According to the progress-free survival (PFS). 116 (76.3%) recurrence or metastasis HNSCC with progress of disease (PD) divided into 4 grades: 15 (12.9%) in every low-risk of PD, 19 (16.4%) in low-risk of PD, 38 (32.8%) in middle-risk of PD, 44 (37.9%) in high-risk of PD. The proportion of cigarettes in the high-risk of PD was significantly higher than other grades (60.00%, 73.68%, 60.53% and 86.36%, respectively, p=0.0431). The distribution of primary pathological differentiation, T stage, N stage was significantly different among four grades. The most predominant R/M or second malignance lesion of low-risk and every low-risk of PD was larynx (73.33%, 57.89%, 7.89%, and 9.09%, respectively, p<0.0001). Prior surgery followed with adjuvant chemoradiation in high-risk of PD were significantly higher than those in low-risk and every-low risk of PD (6.67%, 0.00%, 34.21% and 47.73%, respectively; P=0.0004). Notably, salvage surgeries without microvascular reconstruction apparently improved survival and were the main salvage treatments of low-risk and very low-risk patients (73.33%, 57.89%, 31.58%, and 13.64%, respectively; P=0.0138). Importantly, the short PFS did not significantly correspond to short DFS. Conclusions: The risk-grade classification may favor strategies for predict prognosis of R/M patients and identification likely to benefit from salvage treatments. Due to our risk classification, asymptomatic and local regional recurrence conferred decreased risk of PD for aggressive-recurrence patients. Radical surgical salvage remains the critical strategy for resectable disease, although proper patient selection for microvascular reconstruction is essential. For second R/M disease, patients with low-risk of PD would be possibility benefit from supportive care rather than aggressive re-salvage treatments. Funding: This work was supported by the National Natural Science Foundation of China (No. 62071415), Natural Science Foundation of Zhejiang Province (No. LY21H160031), Medical Health Science and Technology Project of Zhejiang Provincial Health Commission Grants (No. 2019336033 and No. 2020367813). Declaration of Interest: The authors declare that they have no competing interests. Ethical Approval: According to the protocol approved by the Ethical Review Committee of the Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University.

Reconstruction of Intrapelvic Defects Using the Free Anterolateral Thigh Flap: Expanding the Traditional Algorithm.

Reconstruction of intrapelvic soft tissue defects traditionally relies on regional pedicled myocutaneous flaps. However, there remain situations in which local options are unavailable. We review our experience treating intrapelvic defects with the anterolateral thigh (ALT) microvascular free flap. A retrospective, institutional review was conducted from 2014 to 2018 of patients undergoing microvascular ALT flap reconstruction of intrapelvic defects. Four patients were identified in this cohort out of 92 total pelvic reconstruction cases. All patients underwent abdominoperineal resection (APR) for rectal cancer treatment. In the two male patients, pelvic abscesses and bladder leak necessitated soft tissue reconstruction after radiation and APR. In both, regional tissue options were unavailable, and a buried ALT free flap was used for soft tissue reconstruction. Both female patients developed rectovaginal fistulas secondary to their tumor burden, necessitating posterior vaginal wall resections. Prior surgical scars and ostomies made abdominal wall tissue unavailable; thus, free ALTs were used to eliminate intrapelvic dead space and reconstruct the posterior vaginal wall. In all cases, recipient vessels were the deep inferior epigastric artery and vein. Flap survival was 100%. Pelvic reconstruction has traditionally been addressed with local/regional pedicled flaps. In cases where these are unavailable, the free ALT flap is a versatile option when buried for intrapelvic reconstruction or posterior vaginal wall lining. We also propose updating Cordeiro et al.'s classic vaginal defect reconstruction algorithm to include the free ALT flap for type IB cases in which the rectus abdominis is unavailable.